TN 3 (02-97)

NL 00802.015 Completion of the Manual SSA-L8025-U2, Notice of Award

A. INTRODUCTION

The SSA-L8025-U2 is a manual form with preprinted appeal rights. Select captions and paragraphs from those shown below to produce a complete notice. The SSA-L8025 is also on the DOCS for completing the notice on a personal computer.

B. PROCEDURE

1. Completion of Payment Information

Under the preprinted opening paragraph, is caption 1901, “How Much We'll Pay,” followed by three column headings, “Beginning,” “Through” and “Amount Due.” (paragraph 1011, NL 00804.115).

  1. Under the “Beginning” column enter the month, day and year of application or the protected filing date if earlier than the date of application.

  2. Under the “Through” column enter the last month, day and year that the payment amount continues unchanged. If the same payment amount continues through the current computation month, type “Continuing” instead of a month, day and year.

  3. Under the “Amount Due” column enter the actual monthly payment amount. When this amount includes a federally administered optional State supplementary payment, include the following statement directly below the amount due:

    “(This includes $       from the State of (State Name)/ District of Columbia.)”

  4. Repeat payment information as necessary. Show $00.00 if no payment is due.

2. Chart for Completing the SSA-L8025-U2

The following chart provides a list of additional captions and paragraphs to use when you prepare a manual SSA-L8025-U2.

  1. OUR DECISION ABOUT HOW WE'LL PAY YOU (Caption 1919) (Use this caption and the following paragraphs only if there is representative payee involvement.)

NL ReferenceParagraphUse
00804.1851291
1609
Notices to claimant and representative payee — Choose the appropriate paragraph — SSI payments will go to a representative payee.
 1290
1608
Notice to representative payee only — Payee's responsibilities. Choose the appropriate paragraph. (See NOTE: under B.5 that tells how to avoid preparing a separate notice to the representative payee.)
  1. INFORMATION ABOUT YOUR PAYMENTS (Caption 1905) (Mandatory)

NL ReferenceParagraph 
A00804.1661623Recipient is in an institution, and we are sending the eligibility notice in the second or third month of institutionalization but prior to G/K cutoff for reducing/stopping payment in the fourth month.
 1624Recipient is in an institution, and we are sending the eligibility notice after G/K cutoff for reducing/stopping payment in the fourth month.
00804.1151479Retroactive in addition to or without ongoing SSI payments due.
 1486Regular payment due (no retroactive money due).
 1480
1484
Claimant has already received payment for a past period — Choose the appropriate paragraph.
 1012Lead-in for payment of first check.
 1025Claimant has received an advance payment, one-time payment (OTP),and/ or presumptive disability/blindness (PD/PB) payment. Retroactive SSI payment is offset by advance payment, OTP and/or PD/PB payment.
00804.1251046Interim Assistance Reimbursement (IAR) involved (Mandatory if IAR involved).
 IARM01
1069
Six-month exclusion of retroactive SSI payment which is part of an IAR refund check.
00804.1801270Agreement to dispose of excess resources—reminder.
00804.1201040
1041
Claimant received advance payments — Choose the appropriate paragraph.
 1048  
 1483  
00804.2001370Payment due for a retroactive period netted against prior payments.
00804.1601180
MARM55
Adjustment of payments due between members of a couple.
 1186
MARM56
Spouse's application pending.
00804.1301080Filing for other benefits—reminder.
00804.2102526Claimant may be due retroactive payments.
 1440
1436
Overpayment on a prior record — Choose the appropriate paragraph(s).
 1016
1018
 
 1017Overpayment on a prior record — Follows paragraph 1436 or 1018, above.
00804.2051418
1431
Making presumptive disability payments pending final determination.
 1188Award for one member of a couple — presumptive disability payments to other member pending disability determination.
 1432Presumptive disability payments stopped after 6 months — final determination pending.
00804.174DCOM03Children of Armed Forces personnel who live outside the United States.
  1. YOUR PAYMENT IS BASED ON THESE FACTS (Caption 1907) (Mandatory)

NL ReferenceParagraphUse
00804.2351014Tells claimant the first day of eligibility for proration Mandatory.
00804.1451130Tells claimant category(ies) of eligibility — Mandatory.
 1131Spouse is eligible for SSI — Tells the spouse's category(ies) of SSI eligibility.
00804.1901315Tells where the claimant resides — Mandatory.
 2970Says that State rules determine the amount of payment.
 1168Describes the State living arrangement.
00804.1601161
1183
Spouse involvement — Choose the appropriate paragraph(s).
 1185
MARM54
MARM57
 
00804.1551165Describes living arrangement (LA) “C” or “D”.
00804.1501145Describes student status of a child.
00804.1701001
1002
If sponsor-to-alien deeming applies always use both paragraphs.
00804.174DCOM04Child is living overseas with a parent who is in the Armed Forces.
  The following paragraphs address income related issues:
00804.1751240Claimant has no income/deemed income.
 1231Income lead-in paragraph.
 1616Income lead-in for E01.
 2233Lead-in for monthly countable income.
 1280
1281
1282
Windfall offset applies — Choose the appropriate paragraph.
  If the claimant has income, consider:
 1601Income disregards reduce chargeable income to zero.
 1232Describes type, period and amount of countable income.
 1253Claimant received a one-time payment of unearned income.
 1260Claimant receives in kind support and maintenance.
 1258Value of the one-third reduction (VTR) applies.
 1603Claimant has a net loss from self-employment.
 1257Special income disregards apply for earned and/or unearned income.
 1602Student earned income exclusion applies.
 1252Overpayment withheld from income other than SSI. (Do not use in the Ninth Circuit.)
  If the claimant is subject to deeming, consider:
 1249Spouse or parent(s) receives public assistance — no deemed income.
 1601Deemed income does not affect amount of SSI payment.
 1257Special income disregards apply for earned and/or unearned income.
 1604Spouse or parent(s) has net loss from self-employment.
 1248Income of spouse or parent(s) deemed to claimant.
 1234Deemor's income deemed to claimant.
 1254Spouse or parent(s) received a one-time payment of unearned income.
  If the claimant has periods of ineligibility, consider:
00804.1751239N01 — Claimant has excess income.
00804.1651200N02 — Claimant resides in a public institution.
00804.1701216N03 — Not residing in U.S.
00804.1401118N14 — Claimant has not attained age 65.
  If the claimant has a period of ineligibility for disability-related reasons, consider:
00804.200SGAM50
1383
Claimant performed substantial gainful activity (SGA) during a closed period.
 1373Date of onset is later than filing date.
00804.174DCOM04Children of Armed Forces personnel who live outside the United States.
  1. INFORMATION ABOUT YOUR BACK PAYMENTS (Caption 1908) (Use when paragraph 1497 or paragraph DCOM05 below applies.)

NL ReferenceParagraphUse
00804.1801497Claimant will receive a retroactive SSI check(s) and there is no IAR involvement or will receive a retroactive title II check(s)—6-month exclusion from resources applies.
00804.174DCOM05Children of Armed Forces personnel who live outside the United States.
  1. ABOUT YOUR OVERPAYMENT (Caption 1909) (Use when the claimant had an overpayment from a prior application or has an overpayment due to advance payments.)

NL ReferenceParagraphUse
00804.2101441Claimant has an overpayment from a prior application.
00804.1201044
1049
Choose the appropriate overpayment paragraph. These paragraphs give the amount of SSI paid and the amount that should have been paid.
1043Overpayment caused by incorrect advance payment amount — no ongoing payment due. 
  1. IF YOU THINK YOU SHOULDN'T HAVE TO PAY US BACK (Caption 1911) (Mandatory when the preceding caption (1909) is used.)

NL ReferenceParagraphUse
00804.2101434Provides claimant with waiver information — Mandatory with caption 1911.
  1. INFORMATION ABOUT MEDICAID (AND OTHER BENEFITS)(Caption 1915) (Mandatory) (Use “AND OTHER BENEFITS” in the caption only if paragraph 1311 below is used.)

NL ReferenceParagraphUse
00804.1101150
1151
1155
1170
Choose the appropriate Medicaid referral paragraph for the claimant's State of residence. (Use 1155 only when a claimant is currently ineligible for SSI and resides in a State where an SSI application is also a Medicaid application.)
 1146Claimant did not provide third-party liability (TPL) information.
 1149Claimant did not provide assignment of rights (AOR) information.
 1156We are developing for claimant's eligibility under 1619(b).
 1152Recipient resides in or moves to a State in which SSA makes Medicaid decisions. Eligibility for payment is suspended or terminated.
 1189Potential 1619(b) when an aged individual becomes ineligible due to excess income, has countable earned income and resides in a State for which SSA makes Medicaid determinations.
 1196Potential 1619(b) when an aged individual becomes ineligible due to excess income, has countable earned income and resides in a State that makes its own Medicaid determinations.
 1158Reporting responsibilities for 1619(b) eligibles in States with Federal Medicaid determinations.
 1159Reporting responsibilities for 1619(b) eligibles in States with State Medicaid determinations.
 1142Notifies title II widow(er)s age 50-65 who receive SSI of the possibility of special Medicaid eligibility per SI 01715.015B.5.
 1191
1192
1193
Reporting information—Use all three paragraphs under paragraph 1158 or 1159 above.
 1166
1167
1179
Eligible for closed period. Choose appropriate paragraph.
 1147Used only for individuals in State that makes its own Medicaid determinations. Case is referred to State for determination because a Medicaid Qualifying Trust may be involved. This paragraph tells the recipient to contact State Medicaid agency for information.
00804.174DCOM06Child living overseas with parent(s) in Armed Forces.
00804.1901311Mandatory when the State administers its own supplementation program.
  1. WHERE YOU CAN APPLY FOR MEDICAID (Use only when you use paragraph 1142 above under the preceding caption.)

NL ReferenceParagraphUse
00804.1101144(Mandatory paragraph for this caption.) Tells title II widow(er) beneficiaries age 50-65 where to apply for Medicaid (SI 01715.015B.5.).
  1. WE WILL REVIEW YOUR CASE (Caption 1927) (Use only when you have used paragraph 1158 or 1159 above.)

NL ReferenceParagraphUse
00804.1101190(Mandatory paragraph for this caption.) Information for 1619(b) eligibles about continuing disability reviews.
  1. THINGS TO REMEMBER (Caption 1926) (Mandatory)

NL ReferenceParagraphUse
00804.2401482
1615
(Mandatory paragraph.) Notifies eligible claimants about reporting responsibilities. Choose the appropriate paragraph.
 1620Advises claimant to report changes even though no SSI payments due now.
 1481Advises the claimant to refile if he/she believes he/she can qualify for SSI.
 1487Title II decision will be in a separate notice.
 1000Refers to an additional notice in either English or Spanish.
00804.2451598No title II (or additional title II) benefits payable.
00804.2202834Value of the one-third reduction (VTR) may not apply if claimant begins to pay pro-rata share of expenses.
00804.1301606Claimant must file for other benefits.
00804.174DCOM01Blind or disabled children living overseas should contact SSA when they return to the United States.
00804.2101438Claimant may be overpaid.
00804.1901313Claimant waived SSA-administered optional State supplement payment.
00804.1601181Spouse also filed for SSI and will receive a separate notice.
00804.1501456Child is age 18 and does not attend school regularly or over 18 but under 21 and stops attending school regularly.
00804.2001414
1415
1424
1425
Choose the appropriate paragraph to tell a disabled/blind claimant about continuing disability reviews.
00804.2051419Reminder to cooperate. Presumptive disability payments made.
00804.1852489Representative payee will receive a copy of notice.
00804.2071650Introduces paragraph 1651, the enclosure, “SSI RULES THAT HELP SSI RECIPIENTS WORK.”
  1. DO YOU DISAGREE WITH THE DECISION?/HOW TO APPEAL/IF YOU WANT HELP WITH YOUR APPEAL (Paragraph 1726) (Mandatory)

    Appeal rights are preprinted as part of the manual SSA-L8025-U2 and also appear on the FONS version of the notice.

  2. IF YOU HAVE ANY QUESTIONS (Caption (Unnumbered)) (Mandatory)

NL ReferenceParagraphUse
00804.240MISM53Closing paragraphs (Mandatory) —Choose the appropriate paragraph.